Primary Care

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Managed care organizations have been criticized for their use of primary care providers (PCPs) as gatekeepers to control access to specialists as a mechanism to hold down costs. However, a new study shows that the rate at which PCPs refer patients to specialists has little impact on patient costs or outcomes. Thus, efforts to constrain PCP referrals to specialists may be misguided, according to Peter Franks, M.D., and his colleagues at the University of Rochester.

In the study, which was supported by the Agency for Healthcare Research and Quality (HS09397), they analyzed claims data and patient survey data to examine the relationships between PCP referral rates and patient costs, health status, risk of avoidable hospitalization, and care satisfaction. The 1995 claims data included 457 PCPs in an independent practice association and 217,606 adult patients. The survey included 50 patients each from 100 PCPs in 1997-1998.

Unlike previous studies that showed higher costs related to referrals, this study adjusted for differences in patient case mix. After this adjustment, the researchers found no significant relationship between PCP referral rate and costs or patient risk of avoidable hospitalization. The survey data revealed no relationship between the PCP referral rate and patients' self-rated physical or mental health. However, patients of physicians with higher referral rates were slightly more satisfied than were patients of physicians with lower referral rates.

Overall, referral rate by itself was not an important determinant of patient outcomes. Although these results should not suggest that open access to specialists will be cost-neutral, they do not support efforts to reduce referrals by PCPs. The authors also note that containment strategies that restrict referrals to specialists set the stage for competition among specialists and PCPs that may have deleterious effects. Also, more restricted access to specialists is associated with lower patient satisfaction.